The Alabama Department of Public Health (ADPH) is the primary state health agency for the state of Alabama, operating with the mission to promote, protect, and improve Alabama’s health. Public health functions are shared by state and local offices using a three-pronged system. Statewide programs are coordinated through the central office; the eight public health districts have the responsibility for delivering public health services and programs specific to the needs of their designated areas and on the most local level, the 66 county health departments (CHD) work to preserve, protect, and enhance the general health and environment of their individual communities. 

ADPH’s Bureau of Family Health Services (FHS), located in the central office, administers the Maternal and Child Health Services Title V Block Grant Program. ADPH contracts with Children’s Rehabilitation Service (CRS), a division of the Alabama Department of Rehabilitation Services (ADRS), to administer services to children and youth with special health care needs (CYSHCN). Other divisions and programs administered by FHS and ADRS include:

• Title X Family Planning Grant
• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
• State Perinatal Program (SPP)
• Healthy Childcare Alabama Program
• Cancer Prevention and Control Division
• Pregnancy Risk Assessment Monitoring System (PRAMS) Program
• State Dental Program
• Alabama Childhood Lead Poisoning Prevention Program
• Adolescent Pregnancy Prevention Branch

FHS is also home to the MCH Epidemiology Branch which pairs an analytical staff member with each program within the bureau to provide data tracking and reporting support to the program managers. Title V utilizes several of those staff to support the implementation, monitoring, and  evaluation of Title V strategies. 

Alabama Title V program staff collaborate with other ADPH, FHS, and ADRS staff, and with a variety of local, state, and federal organizations in order to assess the magnitude of factors impacting the state of health of Alabama’s MCH population. Program staff rely on these same partnerships to prioritize needs and create methods of addressing current and emerging needs. Considerations of the social determinants of health are also factors in our work to improve health.

FHS and CRS are leading collaborative statewide projects dedicated to improving the health of the MCH population. As part of a 5-year strategic planning reboot, in 2019 ADPH leadership assembled teams to concentrate on five special projects each year. For 2019 one of those projects was Improving Pregnancy Outcomes. On June 20, 2018, the State of Alabama Infant Mortality Reduction Plan was adopted. This plan convened staff from ADPH, the Alabama Medicaid Agency (Medicaid), Alabama Department of  Mental Health (ADMH), Alabama Department of  Early Childhood Education (DECE), Office of Minority Affairs, and the Department of  Human Resources (DHR), and has made great strides in collaborating to improve birth outcomes. The project was implemented in the three counties with an infant mortality rate higher than the overall state infant mortality rate: Macon, Montgomery, and Russell.

A great accomplishment and result of all the state efforts focused on infant mortality is Alabama’s infant mortality rate decreasing to 7.0 infant deaths per 1,000 live births in 2018. This figure is the lowest rate in Alabama’s history.

Coronavirus Disease 2019 (COVID-19)

The operations and services of ADPH, ADRS, and their partners have been greatly impacted by COVID-19. Like all HRSA grantees, we have experienced meeting and training cancellations, postponed medical, mental, behavioral, and dental services in the state, and transitioned to virtual applications. However, we have all become quite creative as we were determined to find means that would allow us to serve the needs of our communities. We continue to seek guidance from our funders and partners, discover new best practices implemented by our fellow HRSA grantees, and implement new policies and protocols as this pandemic rages on and evolves. We have highlighted the manner in which ADPH and ADRS programs, and the citizens of Alabama are adjusting to new ways of living, learning, and working.

The Oral Health Office’s (OHO) initiatives have slowed, mainly because of the closing of dental offices, schools, and Head Start programs. Numerous activities and campaigns, such as the annual Oral Cancer Awareness Month ("Watch Your Mouth") campaign, were cancelled. One significant impact involves the inability of our grant recipient, HandsOn River Region / Pay It Forward, to utilize a large portion of their funds due to the lack of ability to appoint clients in (closed) dental offices. The most significant hindrance that COVID-19 caused is the inability to proceed with the Basic Screening Survey of Alabama kindergarten and third graders on a predictable timeline. The uncertainty of virtual vs in-class learning has resulted in the likely postponement of the survey until predictable in-class scheduling and coordination is feasible later in the academic year. 

All Well Woman (WW) Program initial/new enrollment visits were postponed on March 17, 2020, due to COVID-19 responses. Also, implementation of the WW program expansion to Marengo county planned for FY20 was postponed due to the pandemic. WW social workers and nutritionists provided virtual education on the topics of nutrition, physical activity, tobacco cessation, achieving a healthy weight, prevention and management of hypertension and diabetes, bone health and ways to deal with stress and depression. An increased number of eligible participants have been inquiring about the WW program; the program’s social work staff are keeping a list of those eligible candidates who desire to join the program once initial visits resume. The social workers are staying connected with the current WW participants via phone and by virtual means to verify that the WW participants are maintaining the goals they established during their initial visits and to inquire about any clinical services needed, such as birth control methods and/or other resource needs such as unemployment or local food bank information. WW staff have provided monthly support group meetings via the Zoom platform and hosted fitness classes via Facebook. Also, ADPH nurse practitioners are refilling medications for WW participants by performing telehealth/phone consult visits and face to face visits for those with critical needs.

WIC has continued to enroll new clients and certify existing clients throughout the COVID-19 pandemic via remote means, with electronic food benefits available statewide. Alabama received permission to implement several COVID-19 waivers through September 30, 2020. Current COVID-19 waivers include: 1) physical presence, 2) remote benefit issuance, 3) separation of duties, 4) food package size modifications for whole grain bread due to limited availability, and 5) compliance investigations due to travel limitations. These waivers have been crucial to ensure benefits continue while supporting participant health and social distancing. By implementing COVID-19 waivers, WIC participation remained steady with more than 117,000 participants receiving WIC benefits in June 2020. The updated USDA WIC income eligibility guidelines went into effect in Alabama on June 15, 2020, increasing financial eligibility and making WIC available to more women, infants, and children. Alabama's WIC program will continue remote issuance as it looks for ways to safely reopen WIC clinics to the public. 

ADPH has taken a leading role in responding to COVID-19. ADPH developed webpages to educate visitors about COVID-19. The pages cover topics such as data and surveillance, symptoms and risks, prevention and treatments, and contact tracing, as well as information specific to schools K-12, healthcare providers, health care facilities, and correctional facilities. Visitors can also read the latest COVID-19 news releases which inform the public about upcoming testing sites. There is also a webpage that provides information and resources in Spanish. ADPH staff continue to assist ADPH with COVID-19 response efforts. Staff conduct case investigations and contact tracing, assist with COVID-19 test kit assembly and delivery, provide support for confidential mail notifications, assist in the operation of statewide COVID-19 hotline and e-mail account, deliver test kits and PPE to CHDs, deliver Remdesivir to hospitals, and acquire/distribute KN95 masks and face shields.

MCH Needs

Between 2014-2015 the Needs Assessment for Alabama’s Title V program was collaboratively conducted by ADPH and ADRS, through FHS and CRS, respectively. FHS’ tasks pertained to assessing needs of infants, children and youth, women of childbearing age, and their families. CRS’ activities focused on assessing needs of CYSHCN and their families. The goals of the assessment and related key tasks comprised the framework for the 2015 Statewide Needs Assessment. An analysis of quantitative and qualitative data gathered through web-based surveys, focus groups, key informant interviews, and from select databases and national surveys yielded a variety of issues for the population health domains. After convening several advisory committee meetings, national priority areas and state needs were identified.

ADPH Highlights

The following information is a summary of 2015-2020 priority needs, strategies and accomplishments. 

Well Woman Program

• Program expanded and is currently offered in six counties in Alabama (Butler, Dallas, Macon, Montgomery, Russell and Wilcox).
• Enrolled 479 participants in the program and recorded 1,637 total WW visits
• Incorporated Spanish versions of fliers/outreach material to capture Spanish speaking population

Oral Health Program

• 1,299 maternity patients received maternity care coordination services through the ADPH social work program.
• Partnered with Dr. Casey Daniel at USA Health Mitchell Cancer Institute, and several state and local partners for statewide Oral Cancer Awareness Month Campaign. The campaign slogan was “Watch Your Mouth”.

Between 2019 and 2020 ADPH and ADRS once again collaborated on Alabama’s Title V Program 5-year needs assessment. See section III.C for a detailed overview of the 2020 needs assessment.

Children and Youth with Special Health Care Needs

CRS provides clinical medical services, clinical evaluation services, care coordination, information and referral, patient/family education, and parent and youth connection to serve CYSHCN and their families. Family engagement is supported in partnership with Family Voices of Alabama (FVA) and the Family to Family Health Information Center (FVA/F2FHIC). Coordinated health services are delivered via 14 community-based clinics across eight service districts.

CYSHCN MCH Needs

Lack of or inadequate supports for transition to all aspects of adulthood; lack of or inadequate access to health and related services, especially in rural areas and for services identified as difficult to obtain; and “increase family and youth involvement and participation in advisory groups, program development, policy-making, and system-building activities were selected as the state priority needs for 2021-2025. Public/private partnerships, including agreements with the state's two tertiary-level pediatric hospitals, will enable CRS to bridge gaps in the system of care, thereby increasing the state's capacity to address the health, social, and educational needs of Children with Special Health Care Needs (CSHCN).

Highlights from the current priority needs:

NPM 11: Medical Home

ESM 11.1 - Percent of enrollees in the state CSHCN program with a comprehensive plan of care.

ESM 11.2 - Percent of providers receiving education/training about family-centered care.

Currently, 7,810 or 66.3 percent, of CYSHCN enrolled in CRS have a current comprehensive plan of care.

NPM 12: Transition

ESM 12.1 - Percent of enrollees in the state CSHCN program with a transition plan in place.

There were 3,589 youth ages 14-21 enrolled in the state CSHCN program and 81.8 percent had a Comprehensive Plan of Care.

SPM: Medical Home

ESM 12.2 - Percent of CYSHCN and their families who report that they share in decision-making and partnerships with health care providers.

In partnership with FVA and the F2FHIC, CRS provided 125 youth, families, and professionals education on family centered care at the annual Partners in Care Summit.

CRS Highlights

CRS added capability to our current electronic medical record for physicians working clinics to be able to securely access patient records in a customized application. This allows physicians to readily access records in a secure format that complies with all federal and state mandates while improving services. The CRS State Parent Consultant and Youth Consultants continued to promote Family Engagement activities and were actively involved in planning and developing initiatives as members of the CRS Management Team. Local Parent Consultants (LPC) are full time caregivers of CYSHCN and are in most CRS offices. The LPCs held Local Parent Advisory Committees where families provided input into CRS policy and program changes.

The Craniofacial Orthodontia clinic rule was amended so it was no longer restricted to Medicaid as a payer source. This allowed clients with craniofacial diagnoses which warrant intensive orthodontic intervention to be served when otherwise they would be unable to receive services locally. The clinic provides a multidisciplinary team approach, in collaboration with the UAB School of Dentistry, to provide medically necessary orthodontic evaluation and treatment for children with congenital or acquired craniofacial anomalies who are enrolled in CRS.

COVID-19 presented unanticipated challenges for CRS. At the onset of COVID-19 CRS’s priority was ensuring that families with CYSHCN and staff were staying safe and healthy. CRS State Office staff and District Supervisors immediately began discussions on how to best serve families while taking the Governor’s orders into consideration. Initially clinics were manned by limited staff and other staff were working from home. CRS care coordinators made check-in calls to families. The calls were to ensure that families’ needs were being met and assist with needed services.  District supervisors worked to implement and provide telehealth services for clinics within Medicaid guidelines. Policies for resuming clinics were developed and implemented to ensure the safety of families with CYSHCN.